Learning from Massachusetts

In 2006 Massachusetts passed sweeping health care reform which provided for insurance coverage for nearly all of its residents. In 2010 the Affordable Care Act (ACA) was passed at the federal level which will enact very similar reforms nationally. While the US Senate was debating the ACA, the New England Journal of Medicine (NEJM) published one opinion article after another extolling the ACA’s virtues and making positive comparisons to the benefits that Massachusetts had experienced under its health care reform.

The one incontrovertible measure by which the Massachusetts plan has met its goals is that nearly everyone, 98% of the state’s population, has insurance. That has come at a cost which even the article’s authors admit is unsustainable. Massachusetts is now among the highest states in the country in per-capita health care spending, and health care is taking up a larger fraction every year of the state’s budget, crowding out other priorities. The growth of health care spending in Massachusetts is also consistently higher than economic growth, another indicator that the current system is unsustainable.

One of the justifications of the Massachusetts plan (and of the ACA nationally) was that it would make insurance more affordable for the middle class, but in Massachusetts insurance premiums have become more expensive, and have done so faster than in the rest of the nation.

Other sources, including the Massachusetts Medical Society, inform us that wait times for a primary care physician have skyrocketed and the number of doctors accepting new patients and accepting state insurance plans have dropped. That makes sense and was predicted by critics of the plan. If the number of patients who can seek care at little cost to themselves is suddenly increased without a corresponding increase in the number doctors, longer wait times are bound to result.

So Massachusetts has shown us how to build a system in which everyone has insurance but only few can get to a doctor. One would think that the authors of the NEJM article would conclude that it is a well-intentioned but unsustainable failure and a sobering warning about what we are about to impose on the nation. Instead, they are so wedded to the mirage of universal insurance coverage that they spend the second half of the article discussing desperate ways to save the plan through various cost-cutting measures. These schemes quickly degenerate into an alphabet soup of bureaucratic names like ACOs and the AQC. If any of these manage to cut costs without worsening care, I’ll eat my stethoscope.

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